Vital Signs

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  1. What measures are included in assessing Vital Signs?
    • Temperature
    • Pulse
    • Respirations
    • Blood Pressure
    • Pain
    • O2 Saturation
  2. What is the frequency of monitoring vital signs in the Hospital?
    • Every 4-8 hrs
  3. What is the frequency of monitoring vital signs in the Home Health Setting?
    Each Visit
  4. What is the frequency of monitoring vital signs in the Clinic?
    Each Visit
  5. What is the frequency of monitoring vital signs in the Skilled Nursing Facilities (SNF)?
    Weekly to Monthly
  6. The frequency of monitoring vital signs is determined by what 3 things?
    • Physician's Order &/or Nursing Judgement
    • Client's Condition
    • Facility Standards
  7. When do you measure Vital Signs?
    • On admission to the Hospital
    • Before, during and after a surgery or a procedure
    • After a medication administration
    • When there is a change in a client's condition
    • Before, during and after a blood transfusion
  8. What should you do to be ready to measure Vital Signs? (3 things)
    • -Be organized in approach
    • -Be aware of needed equipment
    • -Know the baseline vital signs for the client and the normal ranges for the population

    (The patient needs to be confident in you)
  9. When should you report Abnormal Vital Signs?
    Immediately
  10. Who should you report Abnormal Vital Signs to?
    • The Student to the Instructor
    • then to the RN
    • then to the Charge RN
    • then to the MD
  11. When should you report Abnormal Vital Signs?
    • When Abnormal
    • When they Return to Normal or Change
  12. How should you report Abnormal Vital Signs?
    • 1st - Verbally to appropriate person
    • 2nd - Document VS in patient's records
  13. Define Temperature.
    The degree of heat maintained by the body
  14. What is the equation for body temperature?
    heat produced - heat loss
  15. The body's Internal Temp. is known as the ______ Temp.
    Core
  16. What is the Normal Range for the body's Core Temp.?
    96.2 - 100.4 F

    36.2 - 38 C
  17. Is the body's Surface Temp. higher or lower than its Core Temp.?
    LOWER
  18. What 2 methods are mainly used to measure the body's Surface Temp.?
    Oral & Auxillary (arm pit)
  19. What 2 methods are mainly used to measure the body's Core Temp.?
    Rectal & Tempanic (ear)
  20. What is the body's Average Surface Temp. Range?
    98 - 98.6 F

    36.7 - 37 C
  21. What is the body's thermostat? Its Thermoregulation?
    The Hypothalamus
  22. Does the amount of temperature increase equate to the degree of illness?
    No
  23. What is more important than the increase in temp.?
    patterns and continuousness
  24. Heat Production can be a result of what 5 things?
    • Metabolism (BMR - thyroid hormones)
    • Skeletal Muscles (break down of fats)
    • Nonshivering Thernogenesis (infants)
    • Shivering (tells hypothalamus to help)
    • Vasoconstriction
  25. Heat Loss can be a result of what 4 things?
    • Radiation (tranfer of heat w/o contact) 50 % of Heat Loss
    • Convection (transfer of heat through air/water)
    • Conduction (transfer w/ contact) 15 - 20 % of Heat Loss
    • Evaporation (transfer occurs when water is convrted to vapor)
  26. What type of Heat Loss is perspiration (sweating)?
    Evaporation
  27. What type of Heat Loss occurs when patient lays on a cold x-ray table?
    Conduction
  28. Where is most of the body's heat lost?
    on the skin
  29. What factors affect your body's temperature?
    Age, Hormones, Exercise, Circadium Rhythm (sleep cylce), Stress & Emotions, Environment
  30. Body Temp. is _______ in the morning and _______ in the afternoon
    lowest, highest
  31. Why do infants wear hats?
    b/c they lose 30 % of their body's temp. through their head
  32. Febrile means ______
    Elevated temperature
  33. Afebrile means ______
    w/o Elevated temperature
  34. Pyrexia means _______. It is a response to _______ or _______ or _______.
    Fever. Bacterial or Viral infections or Tissue Injury
  35. What is the body's temp. when it has Pyrexia?
    Greater than 100.4 F (38 C)
  36. What is the body's temp. when it has Hyperpyrexia?
    Greater than 105.8 F
  37. Is a fever always a bad thing? Why/Why Not?
    • No - Up to 102.2 F can be beneficial b/c it:
    • - enhances immune responce
    • - kills/inhibits many microorganisms
    • - enhances phagocytosis
    • - causes breakdown of lysosomes
    • - virally infected cells self destroy
    • - releases interferons (protects cells from viruses)
  38. What cell damage can a high temperature cause in the brain?
    • Agitation
    • Confusion
    • Stupor
    • Coma
    • Vascular Collapse
    • Death
  39. Heat Exhaustion is:
    profuse diaphoresis (sweating) leading to water & electrolyte loss
  40. Malignant Hyperthermia is a repsonse to _____
    Anesthesia
  41. A Heatsrtoke is:
    • A Medical Emergency
    • Hot & Dry skin
    • no sweating
  42. What are the levels of Hypothermia?
    • Mild = Less than 96.8
    • Moderate = 96.7 - 82.4
    • Severe = Less then 82.4
  43. What are the causes of Hypothermia?
    • cold weather
    • cold water
    • lack of shelter/clothing
    • surgery (coldness can save cells)
  44. What tyoe of thermometer would you use on a patient in isolation?
    Disposable thermometer
  45. An Axillary temp. is _____ than an Oral temp.
    1 degree cooler
  46. A Rectal temp. is ______ than an Oral Temp.
    1 degree warmer
  47. What should you do before you administer a rectal thermometer?
    • Make sure it is marked RED (Rectal)
    • Lube it 1-2"
    • **Stop if you feel resistance**

Card Set Information

Author:
 awnoles
ID:
 40879
Filename:
 Vital Signs
Updated:
2010-10-09 21:01:11
Tags:
Foundations Nursing JSU
Folders:

Description:
Temperature
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